Healthcare Radiology Information Form

HEALTHCARE RADIOLOGY INFORMATION FORM

Date of Request:   Referring Physician:

Patient Information

Date of Birth:   Gender: Male Female Other/Prefer not to disclose

Insurance / Billing Information

Clinical Indication & Prior Imaging

Medical / Safety Screening

Please indicate all that apply to the patient:

Known allergy to medications
Previous reaction to iodinated or gadolinium contrast
Renal disease or impaired kidney function
Currently on dialysis
Diabetes
Taking metformin (an oral diabetes medication)
Pregnant or suspect pregnancy
Breastfeeding
Implanted device or metallic foreign body (pacemaker, cochlear implant, neurostimulator, etc.)
Claustrophobia or inability to lie still

Weight (required for equipment/contrast dosing):

Contrast Media — Consent and Information

Radiologic contrast agents may be recommended to enhance diagnostic accuracy. Contrast administration carries risks including allergic reaction, contrast-induced nephropathy, and other adverse events which in rare cases can be severe or life-threatening. The referring clinician and radiology staff have reviewed the rationale, expected benefit, and alternatives to contrast for this exam.

Please indicate your choice regarding administration of contrast material:

I consent to administration of contrast material as clinically indicated.
I decline contrast administration at this time.

Risks, Alternatives, and Rights

I acknowledge that the nature and purpose of the requested imaging procedure, associated risks commonly known to occur, and any reasonable alternatives have been explained to me in language I understand. I understand that no guarantee has been made regarding the outcome or diagnostic yield of the procedure.

I understand I may refuse or withdraw consent at any time prior to the procedure without jeopardy to other medical care. Withdrawal of consent after commencement of an intervention may not be possible in all circumstances.

I acknowledge that I have had an opportunity to ask questions and that my questions have been answered to my satisfaction.

HIPAA / Release of Information & Authorization

I authorize release of radiology images and reports to the referring physician, other treating providers, and my insurer as required for treatment, payment, or healthcare operations. I acknowledge receipt of the facility's Notice of Privacy Practices and understand how my health information may be used and disclosed in relation to this imaging encounter.

Financial Responsibility: I understand I am responsible for charges not covered by my insurer, including portions for which prior authorization was not obtained. I authorize payment of benefits to the facility where allowed.

Patient Certification

By signing below I certify that the information provided on this form is complete and accurate to the best of my knowledge. I consent to the radiology procedures described above and to the release of relevant medical information for treatment and billing purposes as indicated.

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